Health status of MHD patients
This study found that most MHD patients had normal weight and waist to hip ratio, which reflects that most MHD patients have a good body shape. The results are similar to those of related studies . Also this study found that most MHD patients suffer from other chronic diseases at the same time, among which hypertension and diabetes were the majority. Previous studies also have shown that the underlying diseases in MHD patients were mostly diabetic nephropathy and hypertensive nephropathy [16, 17] and chronic diseases such as hypertension and diabetes may impair the physical function of MHD patients and reduce their quality of life . This study comprehensively analyzed the self-feelings of health status of MHD patients through self-feelings of physical health status, self-feelings of appetite status and self-feelings of sleep quality. However, previous studies only conducted research from a single aspect such as diet status or sleep disorders. In this study, MHD patients had better self-feelings of physical health status, self-feelings of appetite status and self-feelings of sleep quality while previous studies have shown that MHD patients have poor diet status  and a higher prevalence of sleep disorders . The possible reason was that the subjects of this study were all from the coastal areas of Zhejiang Province. According to the national GDP ranking, the economic development level and people's living standards were relatively high in Zhejiang Province. Therefore, there were more choices in diet according to the preferences of MHD patients, which was possible improve the MHD patient's appetite status. In addition, in terms of sleep conditions, previous studies have mostly used objective indicators to evaluate patients’ sleep quality and poor sleep quality had a broader definition. However, this study used subjective indicators to evaluate MHD patients' self-feelings of sleep quality. Patients often think that poor sleep quality is only due to insufficient sleep duration or frequent awakenings.
The quality of life of MHD patients
Among the scores on the dimensions of kidney disease and quality of life in MHD patients in this study, the kidney disease-related burden dimension had the lowest score and the kidney disease-related symptoms dimension had the highest score. This study showed that MHD patients were mainly troubled by exhaustion, itchy skin, dry skin and cramps, which was similar to the results of related studies . Relevant studies have shown that fatigue was one of the most common symptoms of MHD patients, with an incidence of 60%-97% [22, 23] and 46% of MHD patients suffered from moderate or severe skin itching . These symptoms seriously interfered with the normal life of MHD patients and became a common reason for MHD patients' unwillingness to follow regular hemodialysis and were also an important factor leading to poor prognosis of MHD patients. This suggested that medical staff should pay more attention to the symptoms of MHD patients, such as fatigue and skin itching. Also medical staff should improve the clinical compliance of MHD patients by relieving such symptoms, so as to improve the quality of life of MHD patients. On the other hand, MHD patients were more troubled with fluid restrictions, dietary restrictions and stress or anxiety. MHD patients need to appropriately limit water intake, reduce protein intake, reduce phosphorus intake, monitor sodium intake, potassium intake and limit fixed acid. Due to strict dietary restrictions and dialysis-related intestinal reactions, more than 30% of MHD patients will have anorexia symptoms . In addition, studies have shown that MHD patients need to spend a lot of treatment costs for long-term treatment. Long-term pain and huge economic burden often make patients face great pressure and doubt the value of their own existence, so as to face life negatively. At the same time, although MHD can prolong the survival time of patients, but it can not improve the renal function of patients, the shadow of death is always around the patients, resulting in fear, anxiety and helplessness. The physical and mental negative impact seriously interferes with the normal life of MHD patients [25, 26]. This suggests that medical staff and family members need to pay more attention to the emotional changes of MHD patients, and relieve patients' unhealthy emotions through correct guidance.
Influencing factors of the quality of life of MHD patients
This study found that male patients have better physical health, a smaller burden of kidney disease and a higher quality of life. This may be related to the different physical characteristics of male and female. In addition to the development of the disease itself, women’s physiological function declines more significantly as the disease occurs and develops. However, previous studies showed that in the process of facing the disease, the mental state of men is often better than that of women. But this study found no differences in general psychological health scores between male patients and female patients. This may be related to the good level of medical care and the good humanistic care of medical staff. So that medical staff need pay more attention to female patients’ physical conditions.
In this study, patients under 45 years old had the best physical condition and the least trouble with kidney disease-related symptoms. In addition to the effects of the disease itself, as the age increases, the functions of various organs in MHD patients will also decline. The various complications and decline in abilities brought about by aging directly lead to the decline of physical conditions . In terms of the kidney disease impact, the results showed that the patients over 60 years old were less affected, possibly because most of these patients have retired and there are not too many tasks to be completed in time in daily life, so the impact is relatively little. For patients under 45 years old, their employment pressure is high and there are many household chores to deal with, so the impact of kidney disease on daily life is relatively greater.
In terms of educational level, the higher the educational level, the better physical condition and the less troubled with kidney disease-related symptoms. Patients with better education have more ways to obtain disease-related information, can be more proactive in understanding disease-related knowledge and better cooperate with medical staff in treatment. At the same time, patients with a high level of education pay more attention to themselves and are easy to accept new information and knowledge . These suggest that medical staff need to provide more health education knowledge to improve the health literacy of MHD patients, thereby improving the quality of life.
Employed patients were less troubled with kidney disease-related symptoms. However, retired patients had less burden of kidney disease. Previous studies have found that employment could improve patients’ sense of self-esteem and promote their social communication and the physical and social function scores of employed patients are relatively high [29, 30]. So their psychological status and social support were better and they were less troubled with symptoms. This suggests that MHD patients need to actively contact with society and friends, avoid being away from society and need to relieve emotional stress in time. For retired patients, their daily material and spiritual needs are little, their economic income is sufficient to meet their daily needs and their social welfare benefits are relatively good, so their kidney disease-related burden is the smallest.
Unmarried patients had better physical conditions, were less troubled with symptoms of kidney disease and had a higher quality of life. The possible reason was that unmarried patients were younger than other patients and had relatively better physical functions. Previous studies have shown that most married patients cannot perform their duties of supporting their parents and raising children normally and they also need to rely on the care of others, which causes their burden to be heavier . This indirectly causes married patients to become more troubled with the symptoms of kidney disease, which leads to a decline in their quality of life. However, this study showed that married patients had better psychological health. The possible reason was that married patients are more able to obtain family support and relieve negative emotions.
This study found that self-feelings of health status had a greater impact on the quality of life of MHD patients. Patients with good self-feelings of physical health status had better physical and psychological health, were less troubled with symptoms of kidney disease, had less kidney disease impact and less burden of kidney disease and had better quality of life. The possible reason is that patients with good self-feelings of physical health status have a better mental state and a more positive attitude towards disease and they are more confident to overcome disease-related symptoms, while patients with bad self-feelings of physical health status have more depression in their lives. Patients with good self-feelings of appetite status had better physical and psychological health, were least troubled with kidney disease symptoms and had a better quality of life. Relevant studies have shown that decreased appetite will increase protein energy consumption in MHD patients, resulting in decreased nutritional status of MHD patients . This makes the symptoms of kidney disease aggravate the trouble for MHD patients, which indirectly causes the quality of life of MHD patients to decline. However, patients with good self-feelings of appetite status can feel more delicious food when eating, thereby contributing to the balanced intake of nutrients, reducing disease-related symptoms and improving the quality of life. Patients with good self-feelings of sleep quality have better physical and psychological health, were less troubled with kidney disease symptoms, had less burden of kidney disease and had better quality of life. Studies have shown that patients with poor self-feelings of sleep quality were more likely to experience fatigue and excessive sleepiness during the day, which disrupted normal circadian rhythms . In addition, poor self-feelings of sleep quality in MHD patients will aggravate their negative emotions such as anxiety, depression, irritability and cause listlessness, dizziness, drowsiness, fatigue, loss of appetite and other symptoms during the day and they do not have enough energy and physical strength to devote themselves to normal life . Poor self-feelings of sleep quality and symptom distress affect each other and seriously affect the quality of life of MHD patients.
After multiple linear regression analysis, self-feelings of physical health status, self-feelings of appetite status and self-feelings of sleep quality were the influencing factors of quality of life. Patients with poor self-feelings of physical health status, poor self-feelings of appetite status and poor self-feelings of sleep quality had worse quality of life. This suggests that medical staff should pay more attention to the self-feelings of patients. The most intuitive manifestation of a patient's health status is his self-feelings of health. It is necessary to strengthen the dietary guidance of MHD patients. At present, medical staff often only pay attention to what MHD patients can or cannot eat, but ignore their diet preference and appetite , which may cause MHD patients’ poor dietary compliance to doctors' guidance. Medical staff can provide targeted dietary guidance programs based on the main factors affecting the diet of MHD patients and the patient's eating habits, so as to improve the quality of life of MHD patients. At the same time, medical staff should pay more attention to the sleep status and daytime mental status of MHD patients. For patients with poor sleep, it is necessary to guide them to improve their sleep quality by improving their sleeping environment, listening to music, soaking their feet or reducing the use of electronic devices before going to bed.
The limitation of this study is that the samples in this study are all from the coastal areas of Zhejiang Province, which can only represent the situation of the more developed areas in China. However, further research should be conducted on the underdeveloped areas in western China.